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SA N J O A Q U I N Environmental Health Department <br /> COUNTY - <br /> UST SYSTEM RETROFIT OR REPAIR <br /> 1. Site map enclosed? YES [j NO [] <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate and all manufacturer training <br /> certificates for each person installing or testing any component that is repaired or replaced. Ensure a copy of <br /> the"Site Health and Safety Plan" is available on the jobsite as required by Title 8. <br /> 3. Detailed description of work to be completed. List components to be repaired or replaced and attach a <br /> diagram drawn to scale showing location of repairs and/or replacements. If repairing a component, describe <br /> how this will be done. (If adding piping, LIDC's, or other UST equipment, or performing tank top upgrade, <br /> use the UST Installation Application pages 4-8 as necessary for a timely plan review): <br /> Protect work aea, shut off break <br /> Pull Spill container out, replace Hardware, O Rings and re-install spill container <br /> Perform integrity tank test by licensed tank tester <br /> Perform spill bucket testing <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> PN 208952-Bellows Replacement Kit(includes o-rings, split rings, and hardware)for Series 2200 OPW Spill <br /> Container <br /> 5. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES [] NO [] NA <br /> b. Identify contractor performing decontamination: <br /> Name Phone ( ) <br /> Address City Zip <br /> 4of6 <br />